Effective date

This regulation shall be effective on July 30, 1992. Appendix A MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR ___________________ TYPE1 _____________________________ SMSBP2 ____________________________ For the State of ___________________________________________________________ Company Name __________________________________________________________ NAIC Group Code __________________ NAIC Company Code ___________________ Address ________________________________________________________________ Person Completing this Exhibit ______________________________________________ line (a) Earned Premium3 (b) Incurred Claims4 1 Current Year's Experience a. Total (all policy years) b. Current year's issues5 c. Net (for reporting purposes = 1a-1b 2 Past Years' Experience (All Policy Years) 3 Total Experience (Net Current Year + Past Years' Experience) 4 Refunds Last year (Excluding Interest) 5 Previous Since Inception (Excluding Interest) 6 Refunds Since Inception (Excluding Interest) 7 Benchmark Ratio Since Inception (SEE WORKSHEET FOR RATIO 1) 8 Experienced Ratio Since Inception Total Actual Incurred Claims (line 3, col b) = Ratio 2 --------------------------------------------- Tot. Earned Prem. (line 3, col a)-Refunds Since Inception (line 6) 9 Life Years Exposed Since Inception If the Experienced Ratio is less than the Benchmark Ratio, and there are more than 500 life years exposure, then proceed to calculation of refund. 10 Tolderance Permitted (obtained from credibility table) Medicare Supplement Credibility Table Life Years Exposed Since Inception Tolerance 10,000 + 0.0% 5,000 -9,999 5.0% 2,500 -4,999 7.5% 1,000 -2,499 10.0% 500 - 999 15.0% If less than 500, no credibility. 1 Individual, Group, Individual Medicare Select, or Group Medicare Select Only. 2 "SMSBP" = Standardized Medicare Supplement Benefit Plan 3 Includes modal loadings and fees charges. 4 Excludes Active Life Reserves. 5 This is to be used as "Issue Year Earned Premium" for Year 1 of next year's "Worksheet for Calculation of Benchmark Ratios" MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR ____________ TYPE1 _____________________________ SMSBP2 ____________________________ For the State of ___________________________________________________________ Company Name __________________________________________________________ NAIC Group Code __________________ NAIC Company Code ___________________ Address ________________________________________________________________ Person Completing this Exhibit ______________________________________________ line (a) Earned Premium3 (b) Incurred Claims4 11 Adjustment to Incurred Claims for Credibility Ratio 3 = Ratio 2 + Tolerance If ratio 3 is more than benchmark ratio (ratio 1), a refund or credit to premium is not required. If ratio 3 is less than the benchmark ratio, then proceed. 12 Adjusted Incurred Claims = (Tot. Earned Premiums (line 3, col a)-Refunds Since Inception (line 6)) x Ratio 3 (line 11) 13 Refund = Total Earned Premiums (line 3, col a)- Refunds Since Inception (line 6)- Adjusted Incurred Claims (line 12) -------------------------- Benchmark Ratio (Ratio 1) If the amount on line 13 is less than .005 times the annualized premium in force as of the December 31 of the reporting year, then no refund is made. Otherwise, the amount on line 13 is to be refunded or credited, and a description of the refund and/or credit against premiums to be used must be attached to this form. I certify that the above information and calculations are true and accurate to the best of my knowledge and belief. _______________________________ Signature _______________________________ Name - Please Type _______________________________ Title - Please Type _______________________________ Date APPENDIX B FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES Company Name: _____________________________ Address: ____________________________________ _______________________________________ Phone Number: ______________________________ Due March 1, annually The purpose of this form is to report the following on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policy holder. Policy and Certificate # Date of Issuance _______________________________ Signature _______________________________ Name and Title (please type) _______________________________ Date APPENDIX C Instructions for Use of the Disclosure Statements for Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare 1. Section 1882(d) of the Federal Social Security Act prohibits the sale of a health insurance policy (the term policy or policies includes certificates) that duplicate Medicare benefits unless it will pay benefits without regard to other health coverage and it includes the prescribed disclosure statement on or together with the application for the policy. 2. All types of health insurance policies that duplicate Medicare shall include one of the attached disclosure statements, according to the particular policy type involved, on the application or together with the application. The disclosure statement may not vary from the attached statements in terms of language or format (type size, type proportional spacing, bold character, line spacing, and usage of boxes around text). 3. State and federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare supplement policy except as a replacement policy. 4. Property/casualty and life insurance policies are not considered health insurance. 5. Disability income policies are not considered to provide benefits that duplicate Medicare. 6. Long-term care insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits that duplicate Medicare. 7. The federal law does not preempt state laws that are more stringent than the federal requirements. 8. The federal law does not preempt existing state form filing requirements. 9. Section 1882 of the Federal Social Security Act was amended in subsection (d)(3)(A) to allow for alternative disclosure statements. The disclosure statements already in Appendix C remain. Carriers may use either disclosure statement with the requisite insurance product. However, carriers should use either the original disclosure statements or the alternative disclosure statements and not use both simultaneously. (Original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when it pays: hospital or medical expenses up to the maximum stated in the policy Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Original disclosure statement for policies that provide benefits for specified limited services) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when: any of the services covered by the policy are also covered by Medicare Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Original disclosure statement for policies that reimburse expenses incurred for specified disease(s) or other specified impairment(s). This includes expense incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when it pays: hospital or medical expenses up to the maximum stated in the policy Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when: any expenses or services covered by the policy are also covered by Medicare Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services (outpatient prescription drugs if you are enrolled in Medicare Part D) hospice other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Original disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when: any expenses or services covered by the policy are also covered by Medicare; or it pays the fixed dollar amount stated in the policy and Medicare covers the same event Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice care (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Original disclosure statement for other health insurance policies not specifically identified in the previous statements) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when it pays: the benefits stated in the policy and coverage for the same event is provided by Medicare Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance. Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Alternative disclosure statement for policies that provide benefits for specified limited services.) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance. Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Alternative disclosure statement for policies that reimburse expenses incurred for specified disease(s) or other specified impairment(s). This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. Medicare generally pays for most or all of these expenses. This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance. Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance. Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance. Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance. Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). (Alternative disclosure statement for other health insurance policies not specifically identified in the previous statements) IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice (outpatient prescription drugs if you are enrolled in Medicare Part D) other approved items and services This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance. Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP).